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Some States Opting Out of Medicare Rule Requiring Physician Supervision of CRNAs

Independent CRNA practice has existed for over 100 years, yet it wasn’t until recently people have been in a dispute about this autonomy.  It is a confusing issue and not an easy issue to explain.  The first nurse anesthetists were in the military and they primarily worked in times of war.  Catholic nuns many times learned how to administer anesthesia during their nurses training.  The first master’s degrees were mandated in 1982, and had to be instituted by 1990.  This step pushed the profession to another level entirely.  Certified Registered Nurse Anesthetists currently must have a bachelor’s degree in nursing, have a current nursing license, and a minimum of one year experience in a critical care or ICU department prior to starting their graduate CRNA degree program.

Non-supervised CRNA anesthesia care has an impressive record of safety and quality, so why is there so much commotion now?  In November 2001 the anesthesia care rule was first published by the Centers for Medicare and Medicaid.  This rule allows state governors to notify CMS in writing of the state’s desire to opt-out of the federal supervision requirement after meeting the following criteria: consulting with the state’s boards of medicine and nursing, determines that opting out is consistent with state law, and decides that opting out is in the best interest of the state’s citizens. This opt out issue does not regulate or change the current practice of anesthesia by CRNAs in any way.  The actual issue is an insurance reimbursement rule.  It simply states that in order for reimbursement to occur for patients of Medicare and Medicaid, a physician must be present in the room during anesthesia when a CRNA is administering the anesthesia. When a governor opts-out it isn’t about whether CRNAs can practice with or without supervision, only whether Medicare will pay them for it for a certain group of patients.  The governor does not have the power to regulate the supervision of a CRNA.

Medical supervision, direction, consultation, etc. are terms used in various state nurse and medical practice act regulations.  There is no rhyme or reason as to when they are used, in what capacity they need to be enforced, or what they mean. Only 12 states require by law that a physician “supervise” a CRNA’s practice of anesthesia as a matter of law. There are 40 states that do not have any physician supervision requirements for CRNAs in their medical practice laws, nursing practice laws, or their regulations.  Not one state requires a CRNA to be supervised or clinically directed by an anesthesiologist.  In the states that do require physician supervision, the supervising physician does not have to be trained in the practice of anesthesia or have additional qualifications. New Jersey and Washington D.C. are the only exceptions, with
Washington’s exception applying only when a general anesthesia is given.  What constitutes direction or supervision is generally not well defined, if it is defined at all. It is a term that is stated without any reference to what it should mean. 

There are 16 states that have opted out of the federal supervision requirement for Medicare and Medicaid.  Iowa was the first to opt out just one month after the anesthesia care rule came into effect in 2001.  Recent studies confirm that in the 10 years since CRNAs have provided the same safe, high-quality care with or without physician supervision. The Lewin study showed compelling evidence that people living in rural and other areas of the United States where anesthesiologists often choose not to practice benefited from this opt out rule the most.  Nurse anesthetists have been a mainstay in these areas for more than 100 years; providing safe, cost-effective anesthesia care for millions of patients. 

Despite favorable evidence many physician organizations have filed lawsuits against the states taking the opt-out option.  Recently, a California Superior Court judge ruled in favor of independent nurse anesthesiologists.  The ruling was based on the grounds there are no state statutes that require a physician’s supervision for those who have the required CRNA training.

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